Diarrheal diseases are the second leading cause of death worldwide. The vast differential diagnosis includes infectious diarrhea, of which approximately 50% is due to viruses and 15% to bacteria. The criteria for severe acute diarrhea are age > 50 with significant abdominal pain, immunocompromised state, dehydration, febrile, duration of illness > 48 hours, or ≥ 6 stools/24 hours. A previously healthy 50-year-old white female presented with a 4-day history of diarrhea, abdominal pain, and hematochezia. The pain awakened her and was associated with anorexia and vomiting. She reported ingesting medium rare steak, eggs, and shrimp. She worked in a health care facility and had no known sick contacts and no recent travel. Physical examination revealed an afebrile, well-developed female with diffuse abdominal tenderness, no rebound or guarding, and positive hemoccult test. Pertinent laboratory tests included WBC of 12,900 with 79% neutrophils and hematocrit of 31. CT scan showed diffuse colonic wall thickening. Treatment included hydration, pain medication, and empiric antibiotics with stool cultures collected. Colonoscopy revealed extensive mucosal inflammation and biopsies showed acute colitis. Stool cultures were fecal leukocyte positive. One was positive for E. coli O157:H7 and confirmed by the state board of health. Antibiotics were discontinued due to the risk of hemolytic uremic syndrome (HUS). Over the next 2 days, hematochezia slowed, hematocrit stabilized, and no evidence of HUS existed. Typical presentation of hemorrhagic colitis due to E. coli O157:H7 includes severe abdominal cramps, nonbloody diarrhea that may become bloody within 2 to 3 days, and absence of fever. Half of patients report nausea and vomiting. The illness may cause HUS characterized by microangiopathic hemolytic anemia, acute renal failure, and thrombocytopenia. In reported US outbreaks, 23% of patients were hospitalized, 6% developed HUS or thrombocytopenic purpura, and 1.2% died. There is no consensus on therapy for hemorrhagic colitis. Current standard of care includes supportive care with close monitoring of renal function. Evidence suggests early antibiotic therapy increases the risk of HUS by enhancing toxin release from killed organisms. If hemorrhagic colitis is suspected, multiple stool samples should be collected. Currently, only 79% of patients with bloody diarrhea and 40% of those with nonbloody diarrhea receive stool cultures. High clinical suspicion coupled with a thorough history and physical examination help leads to early diagnosis with appropriate management of the patient.
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